On this episode, ABN and Collecting Money from Patients. Stay tuned.

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Welcome to episode 300 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter. And today's episode, we want to talk about ABNs and collecting money from patients, which all sorts of different ways, whether it's cash pay, coinsurance, co-pays. So we wanted to we haven't talked about this topic in a while and wanted to circle back and mark what's new in ABNs and collecting from patients.

Well, I don't know that I would say it's new, but I would say that the realities of where we are right now really is a continued shift in payment from payers to patients, as well as patients really understanding that sometimes insurance isn't the best way to go. So I think we've got a few different options that we can touch on. And you may recall that probably the furthest option we discussed was back in 2025 when we spoke to the physician in Florida who was doing concierge medicine. But more and more we have patients who either know they aren't going to meet their deductible for a year or are in situations where they're seeking services that aren't really covered by insurance plans or not well covered by insurance programs. So you've got a couple of different categories that all this stuff falls into. And that's why we brought up the ABN, because we've got a number of services that we deal with in urology, like infertility and growing erectile dysfunction, where we have flat out benefit non-coverage of treatments for those particular issues. Then we have other things, and unfortunately, erectile dysfunction falls in this category. And we also have services related to maybe some of the incontinence treatments that are out there, and some of the other home diagnosis or home care treatments that are covered sometimes. The things that are covered sometimes, especially by Medicare, are those things that ultimately we need to get ABNs on. And Medicare does have a pathway to make sure that you instruct the patient that this is not something that will be covered by Medicare. There's a specific form that can be downloaded from the Medicare website that can be filled out for that particular date of service. And that date of service needs to be descriptive of the services that are providing, needs to be signed before the treatment is provided to the patient. Those are things that, again, we believe strongly that are not going to be covered by Medicare, and you're shifting that responsibility to the patient. Your private payer contracts may have different rules. The private payer contracts may have contractual language that effectively bars you from charging the patient for services that they might cover and don't allow a separate pathway, which is something that they should start changing and maybe something that you look at changing in your contracts if you're going back to your payers and renegotiating your contracts, which we've recommended before, you do each year, at least asking for a cost of living increase.

Got a question for you on that. And without a lot of teeth on collections as far as threats because of the patient balance not necessarily hitting the credit report from a medical bill. Are you seeing collections being harder to harder to actually collect with these forces?

So add to that the economy, right? In general.

Right.

Yes. I would say that routinely, complaints across the board, patients are one of the hardest groups to collect with. And that's where timing comes into play and discussion with your patients. And I can look at this a couple of different ways, but as a general policy, I would estimate at the very least cost for patients that you believe or know have a deductible that hasn't been met. Make sure that co-pays are clearly noted. And of course, surgical deposits for deductible gaps that are provided or co-insurance. Those are things that if you can get that information off your eligibility checks, you should leverage that information to actually get at least a deposit, if not at least a deposit and a credit card on file, or the full amount before the service is rendered. Too often, patients these days with the ability or the belief that medical debt is not going to hurt their credit unless they're trying to buy a house or a bigger purchase, that it doesn't ding their credit record, those types of things are more likely to ignore that bill as they struggle from month to month. It gets to be habits. So you want to do as much as you can to collect from your patients up front. I would also remind everyone that if the patient always, and I mean always, under HIPAA law, has the right to request that services are provided without billing insurance. This is cash pay. There are a number of folks that have different protocols, procedures, and actually structures to offer services like this. We have a number of practices that have a separate entity, maybe that focuses on men's health or women's health, or maybe even more specific into services that are focused on maybe beauty or wellness that patients are paying for elsewhere, but may be a little more, I don't know, open to from a physician. So as you think about all of these potentials that are out there, including the HIPAA protected way to get services provided without submission to insurance, of course, letting the patient know that this is probably not going to count towards their deductible. There are a number of strategies, including discounted rates with payment up front, to get that those services paid for on a much more retail, patient-direct fashion. And there are plenty of services that we have out there, specifically around the in the incontinence world, with things like the magnetic chairs and maybe some of the intervaginal laser treatments that are available and can be provided and are provided to a number of patients on a cash basis. When you think about all of this, you've got a couple of different pieces that need to be in place. One, obviously, as this episode is focused on how do you collect? You've got to have your upfront people trained to ask for and collect information from patients. You've got to be able to process credit cards and hold credit cards on files and make sure that you can actually follow through on those patient promises so that you have an easier way of collecting that revenue from the patients directly. So there's a few things that you can do in that regard to actually focus on both pricing and on collections that can move some of this into a situation where the patient can get what they need or what they want from you directly without having to navigate the crazy insurance world that's out there. This podcast episode is supported by Eurogen, manufacturer of Zesturi. Zesturi, mitomycin for intervesical solution, is indicated for the treatment of adult patients with recurrent low-grade intermediate risk non-muscle invasive bladder cancer. Please visit zesturi.com for more information.

Are you seeing the larger groups that maybe groups that are owned by corporations or private equity? Are they better at collecting from patients because the groups that are more private that are owned by the physicians, is it harder to say no when you're an owner versus when you're not an owner? Do you see that out there a lot?

So I don't know that I can say 100% that larger groups are really on top of this any better than some of the private groups that are out there, the smaller groups. I can say that the kind of the bigger issue out there is the culture of the practice and more or less the size of the geography that the physician group is serving. The smaller towns and solo practitioners, they see their patients out and about more frequently, and a lot of times that makes it more difficult to have those interactions with the patients. So I think there it's all over the board. And then, of course, the biggest part of it is the overall structure that you lean into. And having a physician who is, in most cases, by nature, more concerned about providing the care and making sure the patient is happy with the results, having the that caregiver or the PA for that matter in the collection role is often much more difficult for folks to really work with. So, and also as you set up processes to collect from the patient, the further you can get that collection piece from the payer into the front, the more you can set it up on policies, the easier it is for your staff to set the culture that's out there. And remember, again, I mean, you've many of you have heard me speak around the country, and I always compare health care and dentistry. Dental care has been provided for years with much of the revenue for those dentists and orthodontists and endodontists coming directly from the patient. It's really about the training that's there. Now, I mean, some people would argue that, well, health care is not as optional as or as dental care, which is on some eyes, some people's eyes, more optional. And so you can be a little more retail in that regard. But there are plenty of services within healthcare that are life-improving, but yet not critical in the health care of the patient. So and most urology practices provide those services. And we give patients choices about treatment for things like BPH and incontinence that certainly would improve their lives that they could choose to pursue if they wanted to. And ultimately, that makes it a bit more retail than something like cancer. So it's not something that you have to set a policy up that's inflexible, but you should set up a policy that really moves the collection off the caregiver with the ability to make exceptions for continuity of care and those things that you're required to do, but also with some type of charity proposal or charity application so that those patients that really need care and really can't afford it fall into that charity category, giving options for the patient, but also taking advantage of maybe some of the tax breaks that are available.

I think those are great points. And I think it's hard to slow down and put in processes and train your people, but I think this is one area that it's uh extremely crucial with these balances and more responsibility on the patients to put that in place because that is the ultimate protection. Those policies and procedures and training really help out in these situations. Just it's human nature. And if you can fall back on a policy and be able to quote that, because as caregivers, physicians, PAs, you want to see that patient healthy and treated. And that that's a hard a hard line to draw. And having that policy that you don't as the person given the point at the point of care don't have to have that discussion, I think is one of the the first things that you need to implement if you're not already doing that. Agreed. Yeah, I mean that you I mean you just understand that that's the the hard part to say no. So Mark, what else what what else is working with a lot of our groups? What do you see? And obviously there's not one size fits all, and you've already mentioned geography and uh as far as population that you're treating, but also probably matters a lot in economic settings as well. So how do you adjust your practice accordingly? Because a lot of those things that you're you may be talking about may work well in the city, but not in the country, may work well in an affluent neighborhood, but not necessarily in uh a poorer setting. How do you go about setting all those up? Is it really just sitting down and talking about it and coming up with what fits best in your practice in your area?

Well, I think there's two things that need to be analyzed to come up with what you can and cannot do. And that really res you know, res that's one of the biggest first steps in all of this is planning. Yeah, understanding your market and your marketplace, and that's where your patients come from, what they have access to or don't have access to as far as financial wherewithal. Obviously, you don't want to set up a plastic surgery clinic in the middle of an area that is not that affluent as a general rule. So you do want to pay attention to that piece. And that's so that's a little bit of market research on the other side. But even a lot of your PPOs and IPAs that are really targeted towards blue-collar workers with maybe not the a load of disposable income and health care isn't maybe their top priority, and certainly not their top spend priority, certainly after they get fixed. Those are where you want to have the ability to collect those copays and those types of things. And ultimately, I would say if you're look looking towards or you think your market has the opportunity to offer maybe some expanded services through a retail-facing market, that you first really get good at collecting copays, deductibles, deposits for surgeries, so that you really build your culture up front. And then, and by that culture, I'm talking not only about the internal culture, but the culture with your patients, really getting them to understand that healthcare is not free just because you've got some insurance. So build that culture first, and you and as Scott mentioned, that training, those tools that really is about that point of care collection is important for any of this. Then, and I also think from the training side, make sure you have repetitive training. These are jobs that tend to turn over because they're more front-facing and a little bit more high stress and maybe not as high paying. So build repetitive programs or videos, things that you can easily train replacements and move them into place. But yeah, ultimately look at your market, look at your own culture. And that may be the other part of this that you really need to consider before you're moving into this realm is do I have my people in the right spot? The front desk person that is the friendliest in the world is a great face to see. But if that person can't collect money and you're trying to do things up front, that may not be the person you want to try and retrain to actually collect money. Now, maybe they can be. That's understanding your people and your personnel. So it's about the personnel, it's about the training, it's about the tools, but it's also about really changing the culture of both your patients and your practice over time to get to the level of retail, if you will, in collecting from the patients.

Yeah, and I think it's worth repeating what you said is it's harder, much harder to collect from somebody after they have their problem solved than before. And so putting your processes in place so that you have that collection piece at the beginning before the service is provided creates a little more urgency on the payment part of things. All right. Anything else you want to add before we wrap this episode up? No, I don't think so. All right. Well, we want to thank our sponsors for this episode, uh, modmed. If you're in the market for an EHR or a practice management system, you can go to modmed.com forward slash PRS for specials for our listening audience. Also, we'd like to thank Eurogen, manufacturers of ZisDuri and Gelmito. You can go to gelmito.com or zesduri.com for more information. All right. Interesting topic today, Mark, and I know we haven't covered it in a while. Any final thoughts?

Generally, I think we covered most of them, but I think the real take-home message here is there are very few patients out there that don't have to pay for their care, at least in part, every time they see you. Letting those patients pass the front gate with balances, skipping co-pays, like the basic block and tackle numbers are going to be a serious hit to your top line and make it more difficult to meet the financial needs and maintain the financial health of the practice. So regardless of where you want to go full retail or not, spend the time and the management energy to get those processes, procedures, training, and tools to those that are in a position to collect what's due from your patients. Very little in this country is free, and of course, generally there's not something as free health care. Somebody's paying for it. It's either you, the insurance company, or the patient. And making sure that it's not you unless you choose to do that through charity or other giving is part of the process that really needs to be fixed within healthcare to maintain a healthy practice.

Great advice. All right. We have a great discussion on this and a lot of different suggestions from people that have been in this situation before. So it's a great time to sit spend two days with like-minded people and learning from not only the PRS experts, but also from your peers. I also want to remind you that the PRS coding and reimbursement hub is available. If you go to PRSnetwork.com forward slash urology hub, you can look up all the different categories we have up there. It's coding advice as well as products. And we're adding to that more and more each week. So we encourage you to check that out as well. All right, that's all we have for today. Thank you all for listening.

Happy coding and collecting.

Thank you for listening to the Urology Coding and Reimbursement Podcast, where we help urologists and their staff maximize income and efficiency so there's time and energy for patient care and a happy life. Special thanks to PowerPointer for the music today. You can find his music on Spotify under its record label User.